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      Improving Survival of Critical Care Patients With Coronavirus Disease 2019 in England: A National Cohort Study, March to June 2020*

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          Abstract

          Supplemental Digital Content is available in the text.

          Objectives:

          To measure temporal trends in survival over time in people with severe coronavirus disease 2019 requiring critical care (high dependency unit or ICU) management, and to assess whether temporal variation in mortality was explained by changes in patient demographics and comorbidity burden over time.

          Design:

          Retrospective observational cohort; based on data reported to the COVID-19 Hospitalisation in England Surveillance System. The primary outcome was in-hospital 30-day all-cause mortality. Unadjusted survival was estimated by calendar week of admission, and Cox proportional hazards models were used to estimate adjusted survival, controlling for age, sex, ethnicity, major comorbidities, and geographical region.

          Setting:

          One hundred eight English critical care units.

          Patients:

          All adult (18 yr +) coronavirus disease 2019 specific critical care admissions between March 1, 2020, and June 27, 2020.

          Interventions:

          Not applicable.

          Measurements and Main Results:

          Twenty-one thousand eighty-two critical care patients (high dependency unit n = 15,367; ICU n = 5,715) were included. Unadjusted survival at 30 days was lowest for people admitted in late March in both high dependency unit (71.6% survival) and ICU (58.0% survival). By the end of June, survival had improved to 92.7% in high dependency unit and 80.4% in ICU. Improvements in survival remained after adjustment for patient characteristics (age, sex, ethnicity, and major comorbidities) and geographical region.

          Conclusions:

          There has been a substantial improvement in survival amongst people admitted to critical care with coronavirus disease 2019 in England, with markedly higher survival rates in people admitted in May and June compared with those admitted in March and April. Our analysis suggests this improvement is not due to temporal changes in the age, sex, ethnicity, or major comorbidity burden of admitted patients.

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          Most cited references7

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          Remdesivir for the Treatment of Covid-19 — Final Report

          John H. Beigel, Kay Tomashek, Lori Dodd … (2022)
          Abstract Background Although several therapeutic agents have been evaluated for the treatment of coronavirus disease 2019 (Covid-19), none have yet been shown to be efficacious. Methods We conducted a double-blind, randomized, placebo-controlled trial of intravenous remdesivir in adults hospitalized with Covid-19 with evidence of lower respiratory tract involvement. Patients were randomly assigned to receive either remdesivir (200 mg loading dose on day 1, followed by 100 mg daily for up to 9 additional days) or placebo for up to 10 days. The primary outcome was the time to recovery, defined by either discharge from the hospital or hospitalization for infection-control purposes only. Results A total of 1063 patients underwent randomization. The data and safety monitoring board recommended early unblinding of the results on the basis of findings from an analysis that showed shortened time to recovery in the remdesivir group. Preliminary results from the 1059 patients (538 assigned to remdesivir and 521 to placebo) with data available after randomization indicated that those who received remdesivir had a median recovery time of 11 days (95% confidence interval [CI], 9 to 12), as compared with 15 days (95% CI, 13 to 19) in those who received placebo (rate ratio for recovery, 1.32; 95% CI, 1.12 to 1.55; P<0.001). The Kaplan-Meier estimates of mortality by 14 days were 7.1% with remdesivir and 11.9% with placebo (hazard ratio for death, 0.70; 95% CI, 0.47 to 1.04). Serious adverse events were reported for 114 of the 541 patients in the remdesivir group who underwent randomization (21.1%) and 141 of the 522 patients in the placebo group who underwent randomization (27.0%). Conclusions Remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with Covid-19 and evidence of lower respiratory tract infection. (Funded by the National Institute of Allergy and Infectious Diseases and others; ACTT-1 ClinicalTrials.gov number, NCT04280705.)
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            Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study

            Annemarie Docherty, Ewen Harrison, Christopher A Green … (2020)
            Abstract Objective To characterise the clinical features of patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United Kingdom during the growth phase of the first wave of this outbreak who were enrolled in the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study, and to explore risk factors associated with mortality in hospital. Design Prospective observational cohort study with rapid data gathering and near real time analysis. Setting 208 acute care hospitals in England, Wales, and Scotland between 6 February and 19 April 2020. A case report form developed by ISARIC and WHO was used to collect clinical data. A minimal follow-up time of two weeks (to 3 May 2020) allowed most patients to complete their hospital admission. Participants 20 133 hospital inpatients with covid-19. Main outcome measures Admission to critical care (high dependency unit or intensive care unit) and mortality in hospital. Results The median age of patients admitted to hospital with covid-19, or with a diagnosis of covid-19 made in hospital, was 73 years (interquartile range 58-82, range 0-104). More men were admitted than women (men 60%, n=12 068; women 40%, n=8065). The median duration of symptoms before admission was 4 days (interquartile range 1-8). The commonest comorbidities were chronic cardiac disease (31%, 5469/17 702), uncomplicated diabetes (21%, 3650/17 599), non-asthmatic chronic pulmonary disease (18%, 3128/17 634), and chronic kidney disease (16%, 2830/17 506); 23% (4161/18 525) had no reported major comorbidity. Overall, 41% (8199/20 133) of patients were discharged alive, 26% (5165/20 133) died, and 34% (6769/20 133) continued to receive care at the reporting date. 17% (3001/18 183) required admission to high dependency or intensive care units; of these, 28% (826/3001) were discharged alive, 32% (958/3001) died, and 41% (1217/3001) continued to receive care at the reporting date. Of those receiving mechanical ventilation, 17% (276/1658) were discharged alive, 37% (618/1658) died, and 46% (764/1658) remained in hospital. Increasing age, male sex, and comorbidities including chronic cardiac disease, non-asthmatic chronic pulmonary disease, chronic kidney disease, liver disease and obesity were associated with higher mortality in hospital. Conclusions ISARIC WHO CCP-UK is a large prospective cohort study of patients in hospital with covid-19. The study continues to enrol at the time of this report. In study participants, mortality was high, independent risk factors were increasing age, male sex, and chronic comorbidity, including obesity. This study has shown the importance of pandemic preparedness and the need to maintain readiness to launch research studies in response to outbreaks. Study registration ISRCTN66726260.
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              The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.

              Amanda R L Frazer, P Sprivulis, Heidi Jacobs … (2006)
              To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. Three tertiary metropolitan hospitals between July 2000 and June 2003. All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Crit Care Med
                Journal ID (iso-abbrev): Crit Care Med
                Journal ID (publisher-id): CCM
                Title: Critical Care Medicine
                Publisher: Lippincott Williams & Wilkins (Hagerstown, MD )
                ISSN (Print): 0090-3493
                ISSN (Electronic): 1530-0293
                Publication date (Electronic): 26 October 2020
                Publication date (Print): February 2021
                Volume: 49
                Issue: 2
                Pages: 209-214
                Affiliations
                [1 ] Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, United Kingdom.
                [2 ] The Alan Turing Institute, London, United Kingdom.
                [3 ] Department of Statistics, University of Warwick, Coventry, United Kingdom.
                [4 ] King’s College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom.
                Author notes
                For information regarding this article, E-mail: bilal.mateen@ 123456nhs.net
                Article
                Accession ID: 00005
                DOI: 10.1097/CCM.0000000000004747
                PMC ID: 7803441
                PubMed ID: 33105150
                SO-VID: b895349e-49c6-4774-8386-f4915a01f861
                Copyright © Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.
                License:

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Subject: Feature Articles
                Custom metadata
                OPEN-ACCESS TRUE
                SDC T

                Keywords: coronavirus infection,critical care,hospital mortality,public health surveillance,quality of healthcare
                Data availability:
                Keywords: coronavirus infection, critical care, hospital mortality, public health surveillance, quality of healthcare

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